Practice guidelines of the European Society of Hypertension for clinic, ambulatory and self blood pressure measurement.
Explore the source record for details and available documents.
Blood Pressure Monitoring, Ambulatory↗
Biomedical subjects
Paolo Verdecchia
Publications and source records attributed to Paolo Verdecchia.
Short- and long-term incidence of stroke in white-coat hypertension.
White-coat hypertension (WCH) has been associated with a low risk for stroke, but long-term data are scanty. We analyzed individual data from 4 prospective cohort studies from the United States, Italy, and Japan that used comparable methodology for 24-hour noninvasive ambulatory blood pressure monitoring (ABPM). Overall, 4406 subjects with essential hypertension and 1549 healthy normotensive controls who were untreated at the time of initial ABPM were followed for a median of 5.4 years up to censoring or occurrence of a first stroke. At entry, mean age of subjects was 56 years (range 18 to 97). Prevalence of WCH was 9%. During follow-up, there were 213 new cases of stroke. Stroke rate (x100 person years) was 0.35 in the normotensive group, 0.59 in the WCH group, and 0.65 in the group with ambulatory hypertension. In a multivariate analysis, the adjusted hazard ratio for stroke was 1.15 (95% confidence interval [CI], 0.61 to 2.16) in the WCH group (P=0.66) and 2.01 (95% CI, 1.31 to 3.08) in the ambulatory hypertension group (P=0.001) compared with the normotensive group. After the sixth year of follow-up, the incidence of stroke tended to increase in the WCH group, and the corresponding hazard curve crossed that of the ambulatory hypertension group by the ninth year of follow-up. In conclusion, WCH was not associated with a definitely increased risk of stroke during the total follow-up period. However, WCH might not be a benign condition for stroke in the long term.
Adult↗
Adverse prognostic significance of new diabetes in treated hypertensive subjects.
Diabetes may develop in nondiabetic hypertensive subjects during treatment, but the long-term cardiovascular implications of this phenomenon are not clear. We determined the prognostic value of new diabetes in hypertensive subjects. In a long-term cohort study, 795 initially untreated hypertensive subjects, 6.5% of whom with type 2 diabetes, underwent diagnostic procedures including 24-hour ambulatory blood pressure (BP) monitoring and electrocardiography (ECG). Procedures were repeated after a median of 3.1 years in the absence of cardiovascular events. Follow-up duration was 1 to 16 years (median 6.0). New diabetes occurred in 5.8% of subjects initially without diabetes. Antihypertensive treatment included a diuretic in 53.5% of these subjects, versus 30.4% of those in whom diabetes did not develop (P=0.002). Plasma glucose at entry (P=0.0001) and diuretic treatment on follow-up (P=0.004) were independent predictors of new diabetes. Subsequent to the follow-up visit, a first cardiovascular event occurred in 63 subjects. Event rate in nondiabetic subjects at both visits, new diabetes, and diabetes at entry were 0.97, 3.90, and 4.70x100 person-years, respectively (P=0.0001). After adjustment for several confounders, including 24-hour ambulatory BP, the relative risk of events was 2.92 (95% CI: 1.33 to 6.41; P=0.007) in the group with new diabetes and 3.57 (95% CI: 1.65 to 7.73; P=0.001) in the group with previous diabetes, when compared with the group persistently free of diabetes. In treated hypertensive subjects, occurrence of new diabetes portends a risk for subsequent cardiovascular disease that is not dissimilar from that of previously known diabetes.
Adrenergic beta-Antagonists↗
Meta-Analysis of effectiveness or lack thereof of angiotensin-converting enzyme inhibitors for prevention of heart failure in patients with systemic hypertension.
We undertook a meta-analysis of large, randomized controlled trials in hypertensive subjects that compared angiotensin-converting enzyme (ACE) inhibitors with different classes of antihypertensive drugs. Compared with subjects randomized to drugs different from ACE inhibitors, those treated with ACE inhibitors did not show a different risk of congestive heart failure (CHF) (odds ratio 1.03, 95% confidence interval 0.96 to 1.12, p = 0.407). The degree of protection from CHF associated with the use of ACE inhibitors showed a nonsignificant trend to increase with age and the degree of blood pressure control. Thus, the hypothesis that ACE inhibitors are superior to other antihypertensive drugs for prevention of CHF in hypertension remains unproven.
Aged↗
Calcium channel blockade to prevent stroke in hypertension: a meta-analysis of 13 studies with 103,793 subjects.
BACKGROUND: The possibility that specific antihypertensive treatments may prevent the occurrence of stroke more effectively than other treatments remains unproved. We undertook a meta-analysis to assess whether calcium channel blockers (CCBs) are associated with a lesser risk of stroke as compared with other antihypertensive drugs. METHODS: Through Medline we identified 13 major studies conducted in hypertensive subjects for a total of 103,793 subjects. Overall, there were 4040 incident cases of stroke, 1789 among 43,053 subjects randomized to CCBs and 2251 among 60,740 subjects randomized to different antihypertensive drugs. RESULTS: Considering all 13 trials, a pooled reduction in the risk of stroke was observed among subjects allocated to CCBs (odds ratio 0.90, 95% confidence interval [95% CI] 0.84-0.96; P =.002). The risk of stroke was significantly lower among subjects allocated to dihydropyridine CCBs than among those randomized to alternative drugs (odds ratio 0.90, 95% CI 0.84-0.97; P =.006), whereas the effect of non-dihydropyridine CCBs did not achieve significance (odds ratio 0.92, 95% CI 0.81-1.04). In a meta-regression analysis of these trials, the protection from stroke conferred by CCBs appeared unrelated to the degree of systolic blood pressure reduction. CONCLUSIONS: These findings suggest that CCBs decrease the risk of stroke more effectively than other treatments in patients with essential hypertension and that such an effect might not be completely explained by a better antihypertensive response. Calcium channel blockers should be considered in hypertensive subjects at increased risk of stroke.
Calcium Channel Blockers↗
Assessment of the optimal daily dose of valsartan in patients with hypertension, heart failure, or both.
BACKGROUND: Recent data suggest that use of relatively high doses of angiotensin II-receptor blockers (ARBs) in hypertensive patients at high cardiovascular risk may reduce the incidence of clinical complications to a greater extent than would be predicted based on blood-pressure (BP) lowering alone. There is also evidence that a sustained reduction in BP, however small, may be important in reducing the risk of cardiovascular disease. Therefore, it is necessary to determine the ARB dosages that optimize the efficacy/tolerability ratio. OBJECTIVE: This article reviews experimental and clinical studies of the ARB valsartan to define the daily dose that provides the best ratio between efficacy and tolerability in patients with hypertension, heart failure, or both. METHODS: Relevant studies were identified through searches of EMBASE and Science Citation Index for articles published before December 15, 2003. No language restrictions were applied. Search terms were angiotensin II-receptor blockers, cardiovascular disease, hypertension, heart failure, type 2 diabetes mellitus, and angiotensin-converting enzyme inhibitors. RESULTS: In several randomized, double-blind, dose-finding studies, the antihypertensive effect of valsartan increased in a predictable fashion over a wide dose range (20-320 mg). The antihypertensive efficacy of the 80-mg dose was enhanced by doubling it to 160 mg, and the tolerability profile remained comparable to that of placebo over a broad dose range. Valsartan has been investigated in patients with heart failure at dosages ranging from 40 to 160 mg BID. Because of the need for careful individualization of therapy in these patients, rigid dose standardization may not be appropriate. CONCLUSIONS: Based on the efficacy/tolerability profile of valsartan at various doses, it appears that 160 mg may be the optimal dose for initial therapy in patients with essential hypertension and in most patients with heart failure.
Angiotensin II↗
Prognostic value of lipoprotein fractions in essential hypertension.
BACKGROUND: To evaluate distribution and prognostic value of total cholesterol and lipoprotein fractions in essential hypertension. METHODS: In a prospective cohort study, 2649 initially untreated subjects with essential hypertension (aged 51, 46.5% women) were investigated at entry and followed for a mean of 5.6 years (range: 1-16). RESULTS: At entry, subjects with total cholesterol (TC) > or =240 mg/dl (> or =6.22 mmol/l) or high-density lipoprotein (HDL) cholesterol (HDL-C) <40 mg/dl (1.05 mmol/l) or low-density lipoprotein (LDL) cholesterol (LDL-C) > or =160 mg/dl (4.13 mmol/l) or TC/HDL-C ratio >6 were 47.7%. TC, HDL-C, LDL-C and triglycerides (TG) did not show any association with office or 24-h ambulatory blood pressure (BP). During follow-up there were 167 first cardiac events and 122 first cerebrovascular events. TC, HDL-C, LDL-C and TC/HDL-C ratio showed an association with cardiac events, but not with cerebrovascular events. TG did not show any association with cardiac or cerebrovascular events. After adjustment for age, sex, diabetes, smoking, left ventricular (LV) hypertrophy and 24-h pulse pressure, the hazard ratio for cardiac events was 1.83 (95% CI 1.23-2.71) in association with a TC > or =6.22 mmol/l, 2.23 with a HDL-C <1.05 mmol/l (95% CI 1.06-4.70), 2.83 with a LDL-C > or =4.91 mmol/l (95% CI 1.48-5.42) and 3.90 with a TC/HDL-C ratio >6.0 (95% CI 2.23-6.81). When forced in the same model, HDL-C and LDL-C showed an independent association with cardiac events. CONCLUSIONS: Abnormalities of TC and lipoproteins are common in essential hypertension. HDL-C and LDL-C independently predict the risk of cardiac, but not cerebrovascular, events. Their predictive value is independent of several confounding factors including LV hypertrophy and ambulatory BP.
Cholesterol, HDL↗
Hypertension and microalbuminuria: the new detrimental duo.
Excretion of albumin with urine (UAE) in small amounts, i.e. microalbuminuria (MAU), also referred to as "incipient nephropathy", has long been considered a marker of early nephropathy and increased cardiovascular risk in the specific setting of diabetes mellitus. However, numerous clinical studies found an association between MAU and other cardiovascular risk factors, target organ damage and risk of cardiovascular disease in clinical contexts different from diabetes and including arterial hypertension. The present article reviews the available evidence on the clinical value of MAU in subjects with primary hypertension. In these subjects, prevalence of MAU varied from about 4% to 46% across different studies and these differences may be explained by the huge intra-individual variability in UAE, discrepancies in the technique of measurement and different definitions of MAU. A direct and continuous association between UAE and blood pressure (BP) has been found in many studies. A continuous association between UAE and left ventricular mass has also been found in most studies. In contrast, it is not yet clear whether the association between UAE and other factors including age, gender, smoking, ethnicity, insulin resistance, lipids and obesity is independent or mediated by confounders, particularly BP. From a prognostic standpoint, several longitudinal studies showed an association between MAU and the risk of future cardiovascular disease. Of particular note, in some of these studies the incidence of major cardiovascular events progressively increased with UAE starting below the conventional MAU thresholds. Thus, besides being a direct risk factor for progressive renal damage, MAU can be considered a marker, which integrates and reflects the long-term level of activity of several other detrimental factors on cardiovascular system. Antihypertensive treatment reduces UAE and such effect may be detected after just a few days of treatment. Among available antihypertensive drugs, angiotensin-converting enzyme (ACE) inhibitors and the angiotensin II receptor antagonists seem to be superior to other antihypertensive drugs in reducing UAE. The dual blockade of the renin-angiotensin system with an ACE inhibitor and an angiotensin II receptor antagonist is a new and promising approach to control UAE in hypertensive patients. Determination of MAU is recommended in the initial work-up of subjects with primary hypertension.
Albuminuria↗
Validation of the A&D UA-774 (UA-767Plus) device for self-measurement of blood pressure.
OBJECTIVES: To determine the accuracy of the UA-774 (UA-767Plus) blood pressure monitor developed by the A&D Company. METHODS: Device evaluation was performed according to the modified British Hypertension Society (BHS) protocol released in 1993. Eighty-five subjects with characteristics outlined in the BHS protocol were recruited among those attending the outpatient clinic of the Department of Cardiovascular Disease, Hospital 'R. Silvestrini', Perugia, Italy. The A&D blood pressure monitor was evaluated according to the various steps of the protocol. Sequential readings were taken for the main validation test. Outcome was classified according to the criteria of BSH recommendations, which are based on four areas of accuracy differing from the mercury standard by 5, 10 and 15 mmHg, or more. RESULTS: The device achieved a grade A for systolic and a grade A for diastolic blood pressure. Mean blood pressure difference (+/-1 SD) between device and observers was -1.01+/-7.14 mmHg for systolic blood pressure and -1.42+/-7.61 mmHg for diastolic blood pressure. There was no systematic change in the device-observed difference over a wide range of blood pressure values CONCLUSIONS: These data show that the A&D UA-774 (UA-767Plus) device satisfies the BSH recommendations for accuracy for systolic and diastolic blood pressure.
Automation↗
Clinical usefulness of ambulatory blood pressure monitoring.
During the past decade, several prospective studies showed that ambulatory BP (ABP) measurements provide a better prediction of major cardiovascular events when compared with clinic BP measurements. This review summarizes the available evidence supporting the use of ABP monitoring to refine prognostic stratification in hypertension. On the basis of available evidence, an operational flowchart is suggested to interpret results of ABP for better treatment of patients with elevated BP.
Blood Pressure Monitoring, Ambulatory↗
Reversal of left ventricular hypertrophy: what have recent trials taught us?
Regression of left ventricular hypertrophy (LVH) is an important intermediate target for antihypertensive therapy. Thus, several trials and meta-analyses have attempted to compare the effects of different antihypertensive agents on LVH, but flawed study designs and methodologic problems have limited the utility of these studies. PRESERVE (Prospective Randomized Enalapril Study Evaluating Regression of Ventricular Enlargement), LIVE (LVH: Indapamide Sustained Release Versus Enalapril) and LIFE (Losartan Intervention For Endpoint reduction in hypertension) represent a new generation of large well designed trials with the power to compare different antihypertensive drugs. These studies have shown that treatment regimens based on enalapril and a nifedipine gastrointestinal therapeutic system are of similar efficacy (PRESERVE), that indapamide sustained release (SR) is superior to enalapril (LIVE), and that a regimen based on losartan is superior to a regimen based on atenolol (LIFE) in reversing hypertensive LVH. LIVE incorporated on-treatment echocardiographic quality control, with centralized readers blinded for both treatment and sequence of recording. The findings of these rigorous studies, to some extent in disagreement with results of previous meta-analyses, support the notion that antihypertensive drugs need to be judged on their individual effects on important intermediate endpoints such as LVH in well designed and adequately sized studies. However, extrapolation of the results of these studies in terms of class effects could be misleading and should be made with caution.
Antihypertensive Agents↗
Regression of left ventricular hypertrophy and cardiovascular risk changes in hypertensive patients.
Hypertensive left ventricular hypertrophy (LVH) may be detected in about one third of people with hypertension. When an individual with elevated blood pressure develops LVH, the risk of adverse cardiovascular events in the ensuing years almost doubles even in the absence of symptoms. Because of this high added risk, hypertension and other modifiable risk factors should be managed aggressively with lifestyle measures and drugs. LVH can be considered a biological assay which reflects and integrates the long-term exposure not only to pressure overload, but also to several hemodynamic and non-hemodynamic factors which may promote progression and instabilization of atherosclerotic lesions and, ultimately, lead to adverse clinical events. LVH can partially or totally regress following antihypertensive treatment and lifestyle changes including losing excessive weight and decreasing salt intake. Angiotensin II antagonists and ACE-inhibitors seem to be the most effective drugs for reversing LVH. Evidence is accumulating that regression of LVH is associated with a significant reduction in the subsequent risk of cardiovascular disease. According to a recent meta-analysis, effective reversal of LVH is associated with a 59% lesser risk of subsequent adverse events as compared with the persistence or new development of LVH.
Age Distribution↗
Association between periodontal disease and left ventricle mass in essential hypertension.
Chronic periodontitis has been associated with an increased risk for cardiovascular disease. Left ventricular mass is an established independent predictor of cardiovascular disease. In the present cross-sectional study, we tested the association between periodontitis and left ventricular mass in subjects with essential hypertension. One hundred four untreated subjects with essential hypertension underwent clinical examinations, including echocardiographic study, laboratory tests, and assessment of periodontal status according to the community periodontal index of treatment needs (CPITN). With increasing severity of periodontitis, there was a progressive increase in left ventricle mass. Mean values (g/height2.7) were 39.0 (+/-2.7) in CPITN 0 (periodontal health), 40.2 (+/-6.4) in CPITN 1 (gingival bleeding), 42.7 (+/-6.8) in CPITN 2 (calculus), 51.4 (+/-11.7) in CPITN 3 (pockets 4 to 5 mm), and 76.7 (+/-11.3) in CPITN 4 (pockets > or =6 mm) (overall F 51.2; P<0.0001). Body surface area (P=0.04), systolic (P<0.0001) and diastolic (P<0.01) blood pressure, and left ventricular mass (P<0.0001) were determinants of a composite of CPITN 3 and 4. In a multivariate logistic analysis, left ventricular mass was the sole determinant (P<0.0001) of CPITN stages 3 and 4. Our findings suggest a direct association between severity of periodontitis and left ventricular mass in subjects with essential hypertension. Periodontal evaluation might contribute to refine cardiovascular risk assessment in hypertensive subjects.
Cardiovascular Diseases↗
[The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure: the weapons are ready].
The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) has recently came to light in a short version. A complete version will soon be available. JNC 7 is the last attempt to bridge the big gap between the current availability of potent and well tolerated antihypertensive strategies and their poor implementation in the clinical practice. Some new and important features characterize the JNC 7 document. The aim of the new and challenging definition of pre-hypertension (BP 120-139/80-89 mmHg) is to sensitize the general population and health professionals to implement effective strategies for a healthier life in order to prevent hypertension and related cardiovascular disease as early as possible. Stage 3 hypertension has been deleted and merged with stage 2 (systolic > or = 160 or diastolic > or = 100 mmHg). BP levels to achieve with treatment (goals) are < 140/90 mmHg (< 130/80 mmHg in diabetics). To reach the goal, diuretics are recommended for initial treatment in most subjects with stage I hypertension. However, combination of at least 2 drugs is recommended if initial BP is 20/10 mmHg higher than goal BP. Apart from the definition of pre-hypertension and the advice to begin therapy with diuretics in most patients with stage 1 hypertension, JNC 7 shares several positions with the hypertension guidelines recently released by the European Society of Cardiology and European Society of Hypertension. JNC 7 seems to dedicate limited space to stratify the level of cardiovascular risk in the individual subjects on the basis of the different combinations between BP levels and concomitant risk factors. In summary, JNC 7 is an updated and well equipped arsenal of formidable weapons against hypertension and its complications. The stage is now set for an hard task: their effective implementation in the clinical practice with the aim to decrease cardiovascular morbidity and mortality.
Cardiovascular Diseases↗
When can the practicing physician suspect white coat hypertension? Statement from the Working Group on Blood Pressure Monitoring of the European Society of Hypertension.
Explore the source record for details and available documents.
Blood Pressure Determination↗
Improved cardiovascular risk stratification by a simple ECG index in hypertension.
BACKGROUND: We determined the prognostic value of the Cornell/strain [C/S] index, a simple electrocardiographic (ECG) index for left ventricular hypertrophy (LVH) defined by the presence of either a classic strain pattern or a Cornell voltage (sum of R in aVL + S in V(3)) >2.0 mV in women or 2.4 mV in men, or both. METHODS: In a prospective, cohort study, 2190 initially untreated subjects (age 51 [+/- 12], 47% women) with essential hypertension without prior events were followed for up to 14 years (median, 5 years). RESULTS: Prevalence of LVH at entry was 16.3% by using the C/S index, which yielded 33.6% sensitivity and 91.0% specificity. Other ECG criteria for LVH including Sokolow-Lyon, Romhilt-Estes, Framingham, Cornell, and strain alone, achieved a lower sensitivity and prevalence. Over the subsequent follow-up, 244 patients experienced a first major cardiovascular event. Event rate (x 100 person-years) was 2.01 in those without and 4.44 in those with LVH by the C/S index (P <.001). After adjustment for age, sex, smoking, and other counfounders, the C/S index identified subjects at increased risk of events (relative risk 1.76; 95% confidence interval 1.32-2.33). The C/S index achieved the highest population-attributable risk (16.1%) for cardiovascular events. CONCLUSIONS: A simple ECG index that can be quickly measured from nondigital machines and without algorithms identifies LVH in a consistent proportion (16.3%) of hypertensive subjects. The LVH defined by such technique allows identification of individuals at high risk for cardiovascular events.
Aged↗
Changes in cardiovascular risk by reduction of left ventricular mass in hypertension: a meta-analysis.
BACKGROUND: Some studies have suggested that serial changes in left ventricular (LV) mass in hypertensive subjects predict the subsequent risk of cardiovascular disease. The aim of this meta-analysis was to evaluate the prognostic impact of LV hypertrophy regression in hypertension. METHODS: We undertook a meta-analysis of studies that reported echocardiographic LV mass before and during antihypertensive therapy, with subsequent assessment of cardiovascular events. The aims of this meta-analysis were: 1) to compare subjects with LV hypertrophy (LVH) during treatment (persistence or new development of LVH) with those with LVH at baseline, but not during treatment (regression of LVH); and 2) to compare subjects with LVH at baseline, but not during treatment with those without LVH both before and during treatment (regression of LVH versus persistently normal LV mass). RESULTS: The four eligible studies included 1064 hypertensive subjects (41% women) aged 45 to 51 years who repeated the echocardiographic study 3 to 10 years after the initial examination. The definition of LVH was based on a LV mass corrected by body surface area >125 g/m(2) in two studies and >110 g/m(2) (for women) and 124 g/m(2) (for men) in two studies. Compared with subjects with lack of regression or new development of LVH, those with LVH regression showed a reduced risk of subsequent cardiovascular disease (odds ratio 0.41, 95% CI 0.21 to 0.78, P =.007). Compared with subjects with regression of LVH, those with persistently normal LV mass showed a similar risk of subsequent events (odds ratio 0.64, 95% CI = 0.31 to 1.30, P =.21). CONCLUSION: Compared with persistence or new development of LV hypertrophy, regression of LV hypertrophy during antihypertensive treatment is associated with a marked reduction in risk for subsequent cardiovascular disease.
Echocardiography↗
European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement.
Explore the source record for details and available documents.
Blood Pressure↗